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STATE OF CALIFORNIA WATER RESOURCES CONTROL BOARD <br /> FORM 'AN: <br /> UNDERGROUND STORAGE TANK PROGRAM � Z <br /> o <br /> SITE FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION Ifs <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> OaN <br /> MARK ONLY ❑ 1 NEW PERMIT ❑ 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE I-a <br /> ONE ITEM 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSURE -I <br /> 1. FACILITY/SITE INFORMATION &ADDRESS- (MUST BE COMPLETED) 00 <br /> FACILITY/SITE NAME CARE OF ADDRESS INFORMATION <br /> ADDRESS <br /> S/S NEAREST CROSS STREET ✓8.0.* A ❑ PAFINERSA 11 STATE.AGENCY <br /> 1 � 101CORPORALS 11LCgMTYGUICY ❑FEDERAL-AGENCY <br /> CIN NAME STATE ZIP CODE <br /> � SITE PHONE A.WITH AREA CODE <br /> TYPE OF BUSINESS. ❑ 2 DISTRIBUTOR ❑ 4 ESSO ✓Box if INDIAN EPA ID N <br /> ❑ I GASSTATION ❑3 FARM ❑ 5 HER RESERVATION <br /> or - Bof TANKS <br /> TRUSLl AT THIS SITE <br /> EMERGENCY CONTACT PERSQN(P ) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(LAST,FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) <br /> PHONE N WITH AREA CODE <br /> NIGHTS'. NAME(LAST,FIRST) PHONE N WIT AREA CODE NIGHTS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> t. <br /> 11. PROPERTY 6WtRIN RMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION j <br /> I <br /> MAILING or STREET ADD SS I/Box to Indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> El CORPORATION ❑ LOCAL-AGENCY ElFEDERAL-AGENCYEl ND <br /> CITY NAME ❑ COUNTY-AGENCY <br /> STATE ZIP CODE PHONE N,WITH AREA CODE <br /> III. TANK OWNER INFORMATION & ADDRESS - (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Box to indicate ❑ PARTNERSHIP ❑ STATEAGENCY❑ CORPORATION ❑ LOCAL-AGENCY Cl FEDERAL-AGENCY <br /> El INDIVIDUAL IJCOUNTY-AGENCYCITY NAME STATE ZIP CODE PHONE A.WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOK INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: I. ❑ it. ❑ BE❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE, IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY R JURISDICTION N AGENCY N FACILITY ID N N of TANKS B1 SITE <br /> CURRENT LOCAL AGENCY FACILITY ID F APPROVED BY NAME PHONE If WrTH AREA CODE <br /> :, )(, 1' S ZS <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION DATE c <br /> LOCATION CODE CENSUS TRA TO SUPERVISOR-DISTRICY DE BUSINESS PLAN FILED DATE FILED <br /> YES NO <br /> 'y <br /> CHECK N PERM MOUNT SURCNARG AMO T FEE CODE RECEIPT N BY: <br /> FORM <br /> TMI FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FO R M 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> (3-2-68) <br /> vDATA panCFccru�rnoo <br />